Translator: Silvana Loli
Reviewer: Helena Bowen One of my most deeply imprinted
childhood memories came on a day when my mom
picked me up from middle school. We rolled to a stop at a red light, and I asked her a question
from the passenger seat. When she didn’t respond,
I looked to see why. She was trembling and tears
were starting to come down her cheeks. She reached her arm over to mine
and she said, “You’re going to be OK.” I said, “What do you mean?” She said, “You’re going to be OK.
You don’t have cancer.” In my innocence, I just realized
that the intense health care tour I had been through
all lead to that moment. Months prior, they found
a lump underneath my chin. The lab tests were run. I toured the country
and visited specialty hospitals, and surgeons removed a mass
underneath my right arm the size of a softball. Until finally my mom got the call. She heard her new favorite word: benign. But in reality, my health care
tour started much earlier. I had an aggressive skull surgery
as a baby to correct the shape of my skull because doctors said I would be
socially unacceptable without it. I was hospitalized as a teen because I had a pneumonia
that was non-responsive to antibiotics. Doctors had to physically insert
a chest tube between my ribs to drain the fluid from my lungs. It extends to today, where
I stand here, quite literally, because I take a weekly injection to treat
arthritis that would otherwise cripple me. And as painful as it is, I compare
my mom’s experience to the experience of a mother
I spoke with in Nepal seven years ago. It was a mother of a malnourished girl, and we were talking because there’d just been a new treatment
introduced in her community: a simple paste that allowed her
to treat her daughter at home. So I asked, “What did you do
before this existed?” After a long pause, the translator responded
hesitantly and said, “The mother said the only available
prescription before this was to wait to let her child die.” I was stunned. Never before had I felt such indignation,
not at the mother of course. Her statement was not
a reflection of apathy. It was a reflection of desperation. I’m deeply troubled by this,
because I believe they way we design our healthcare systems
speaks about our identities as a society. The choices we’ve made to date
put the values we all share at risk. No one would ever willingly place
a mother in the position where she didn’t have
a treatment for her child and no one would ever wish
for a hardworking family to go bankrupt due to the cost
of their medical bills in the world’s wealthiest country. Yet, these are the two health care
worlds I move between. Here, a system of excess. There, a system of access. And confronting that reality created the driving
question of my career: can we design health care systems
that meet our moral aspirations? I’m here because we can, and it’s very easy to say that this is all
just about money, to dismiss it that way. That if people in Nepal and places
like Nepal were just wealthier their health care problems would go away. But you don’t need to look beyond the failures of the U.S. health care
system to see that that’s not true. It’s undeniable that we get low value
for tremendously high cost. Why? It’s a design issue. We have a more-is-better mindset, and it’s exaggerated by
a fee-for-service payment structure that creates the wrong incentives. This more-is-better mindset
rewards clinicians for giving excess care
that satisfies patients’ desires, instead of solving for patients’ needs, even if it demands
fewer medical interventions. This is extremely costly. In 2011, we spent 226 billion dollars on unneeded prescriptions
and procedures. Even worse, is that the way
we pay for health care in this country has become a form of trauma itself. The leading source of personal bankruptcy
is paying for medical bills, and it’s responsible for an astonishing
57% of personal bankruptcies. So you can’t really argue
that this is just about money. Yet, what I find strange
is that people believe that exporting this system of excess to places that are struggling
with access provides an answer. We see countries all over the world
combining a more-is-better mindset with the irresistible incentives
of a fee-for-service model, and all they’re getting is a pretty poor
nickel-and-dime approach to health care that leads their most disenfranchised
in a terrible place. Every year we have 100 million people
that are driven into extreme poverty by paying for health care out-of-pocket. That’s worth saying again: health care is the driving force pushing 100 million people
into extreme poverty every year. So if this system of excess
that we have here isn’t going to provide the answer
to places that are struggling with access, where do we look? Well I’ve had the great privilege,
working over the last few years with an incredible team, trying to build health care systems
in the world’s most impossible places. Places like this in rural Nepal, located 36 hours by bus one way
from the capital city of Kathmandu, where people make an average
of under $200 per year, and are offered very little
in terms of basic services, like roads, electricity, and water. What I’ve found during this pursuit is that an unlikely idea
is holding us back. That idea is the idea of sustainability. Now I know there is risk
in trying to take down sustainability, especially in Colorado,
but let me explain. Very few people know that
we have gone through two great eras where we attempted to define
sustainable health care, yet all it lead to was widespread
misuse of the idea. In 1978, world leaders convened upon
Kazakhstan to sign a declaration that said we would have
health care for all by the year 2000. But what happened as a result
was that we didn’t commit to building health care systems
that worked fully for the poor; we chose a path of selective health care. Essentially a basic minimum package that made it pretty easy to go after
the low-hanging fruit. Because this in theory was cheaper
and easier to execute, it became our definition
of sustainability. So we lowered the bar. Then in the early 90s, when we saw
that we were very much off the mark to hit health care for all by 2000,
we made another attempt. We pursued an aggressive
fee-for-service approach, saying that this would only happen
if the poor were put in a position where they would have to pay
for each of their services. So what you get when you put together
both of these attempts is a definition of sustainability that equates to a minimum
package of health care, and special rules for the poor that we would never allow
to be applied to those we love. So where does this leave us? I would argue that sustainability
is not a benign term as it relates to healthcare for the poor. That it’s actually lead
to vast failures of imagination, and it’s prevented us from building
health care systems from the way they need to be built. But now we’re in a different era. I’m actually gonna just go and say I think
we should just do away with the word sustainability
as it relates to health care all together. I think it’s too flimsy, it has a scarred history of being used
against the poor, and we can do better. We need to move away from the errors
of sustainable health care and pursue a new approach:
something I call durable health care. Durability demands
more than sustainability. Sustainability is based on satisfying
patients who can pay. Durability is based on
solving for patients regardless of their position in society. Sustainable health care means
something different for different people, but durable health care
is one clear promise: it says we’ll build health care systems
the poor can rely on to escape poverty, rather than be one
that drives them further into it. Durable health care
is also a system design that helps us avoid the failures
of traditional approaches. After years of working in Nepal, we realized that these traditional
models have their failings, that none of them alone
fully solve for the poor. The private sector
isn’t accessed due to cost, the public sector often fails
to deliver in quality, and the philanthropic sector, though it can create
great pockets of excellence, never achieves the scale needed. Yet each of these sectors
also has strengths. The private sector can execute effectively
with great management. The public sector provides access
to its country’s poorest citizens. The philanthropic sector allows us
to take risks and to innovate. So what durable health care does is that it combines the strengths
of these three traditional approaches. The way it does that is it puts
a non-profit health care company inside the government’s existing
health care infrastructure and asks that company
to deliver health care, and it says that that company
can only get rewarded with financing if it gets the results that really matter. Now this brings together
the strengths of the sectors. It allows the government to provide
the infrastructure and financing. It allows the company to provide
the management acumen and it gives them the financial engine
to get the results we all want to see. But because that company is a non-profit, it means that the financial engine
can be driven by cost recovery, and not profitability,
and that changes everything. It means a non-profit health care company
can dare to go to markets where the private sector didn’t
previously see any opportunity. They can go there and they can combine
government funding and philanthropy to build those systems we want to see, the ones that work fully for the poor. Because the incentives are very different
than our system of excess, we remove ourselves from the trap
of more-is-better and fee-for-service. So delivering durable health care
is more than just a dream. Governments around the world
are looking for better opportunities to serve the poorest in their countries. We’ve come to terms a bit with our history
with sustainability and realized that it’s been a bit misguided. What we need now is to put aside
our ideological boxes to put the poorest patients
at the center of our health care design, and to get clinicians
in front of those patients with the incentives to do the right thing. What will emerge is a durable health care
that does meet our moral aspirations, that honors the dignity of the poor and allows us to say to more patients
what my mom said to me: “You’re going to be OK.” Thank you. (Applause)